Common Insurance & Billing Questions

  • What are co-pays and co-insurance? When are they due?
  • What are deductibles? When are they due?
  • How do I know if my doctor is on my insurance plan?
  • How do I know what services are covered under my insurance?
  • Can I still be seen if I don’t have insurance?
  • What if my insurance does not cover preventive care or I have a preventive care maximum benefit?
  • Why do you need my Medicaid or insurance card at every visit?
  • Can you change how you billed my child’s visit so my insurance will pay the claim?
  • Can you bill my ex-spouse?
  • How do I know when my claim has been processed by my insurance?
  • What if my insurance denies my claims for pre-existing conditions?
  • What if my insurance denies a service as non-covered?
  • How do I know which of my insurance policies is primary, and which is secondary?
  • What if my insurance policies are both paying as primary or denying claims?
  • How do I add my newborn to my policy?
  • What can I do if I don’t agree with the way my insurance processed my claim?
  • What is timely filing? How do I know if my insurance has timely filing? 

What are co-pays and co-insurance? When are they due?

-- Co-pays are the amount you are required to pay by your insurance when you receive health care. It is usually a set dollar amount (i.e. $20.00). Co-insurance is usually a percentage of the allowed charges (ie.20%). For example with co-insurance your insurance may pay 80% of the allowed charges and you will have to pay the remaining 20%. Your insurance card will usually specify what the co-pay or co-insurance is.

-- Co-pays and co-insurance are due at the time of service, prior to seeing the doctor. Your insurance card should specify what your co-pay or co-insurance is. If the amount is unknown, you will be asked to pay a specific amount at the time of service. You will be billed for the difference or your account will be credited if you overpaid.

 

What are deductibles? When are they due?

-- Deductibles are the specific amount you must pay before your insurance starts to pay a portion of the costs for a covered health expense. When you have met your deductible amount as specified in your contract, your insurance will start to pay claims within your plan benefits.

-- Deductibles are due at the time of service. You will be required to pay a minimum of $50.00 for a doctor visit and $100.00 for a well child check up before seeing the doctor. We will submit your claim to the insurance company for the full charge so they can apply the services toward your deductible. You will be billed for any differences between what you were charged at the time of service, and what the insurance company applied to your deductible.

 

How do I know if my doctor is on my insurance plan?

-- Our website lists most of the payers we are contracted with. Some of these payers are national, or have some plans that are contracted through a third party that we may not be participating with. In order to determine if your doctor is participating with your plan, call your insurance and give them the doctors’ name. They have access to your plan and the most up to date contract information. You will want to verify this prior to your visit.

 

How do I know what services are covered under my insurance?

-- Your insurance benefit manual will go over what is covered under you plan. You can always call your insurance and they can pull up your plan to specifically go over what is covered.  However, they will not guarantee payment until after the claim is processed. If you are wondering about specific services you will receive, we can provide the codes so you can get more accurate information from your insurance.

 

Can I still be seen if I don’t have insurance?

-- We do accept self-pay patients. You will receive an 18% discount when payment in full is made at the time of service. We are able to give that discount because we will not need to use time or resources to collect the payment after the fact. If payment is not made at the time of service you will be responsible for the full amount with no discount. We can set up payment arrangements to bring your account current.

 

What if my insurance does not cover preventive care or I have a preventive care maximum benefit?

-- Preventive care visits are very important for the health and proper development of your child. Many insurance plans do not cover preventive care services, or have a maximum allowance per year. If your plan does either of those, the State of Utah has programs to help you manage the cost of those visits. Once your maximum preventive care benefit has been met or your plan does not cover immunizations, you are eligible for the Vaccine for Children (VFC) program. This program provides immunizations at no charge, you will only have to pay for each injection to be administered. It is your responsibility to know what immunizations are not covered or that your maximum benefit has been met. You will need to tell the nurse and/or doctor what is not covered or that you have met your maximum benefit before the immunizations are given.

 

Why do you need my Medicaid or insurance card at every visit?

-- Eligibility with Medicaid goes month to month. While your ID number will stay the same, the HMO, PCP or other critical information may change. Those changes can affect your benefit coverage. If Medicaid denies your claim for eligibility reasons, we will need a copy of the card for that month in question in order for Medicaid to honor the claim.

-- Presenting a copy of your insurance card at every visit will ensure your claims get processed correctly according to your plan benefits. While your actual insurance may not have changed it is common that the id and or group number will change, even by only one number or letter. Those little changes, if not updated can affect your claims being processed.

-- If we do not receive a copy of your current insurance card we will set your account up as self-pay until we receive that copy.

 

Can you change how my child's visit was billed so my insurance will pay the claim?

-- The doctors’ records state what was done at the visit (i.e.: type of visit, immunizations, labs, tests, ect.). We are required to report what services were done at every visit. It is fraudulent to change the diagnosis and/or services just so your insurance will pay them. The only way a claim can be changed is if it was reported incorrectly to the insurance.  It is advised that you contact your insurance before being seen to determine what will be covered.

 

Can you bill my ex-spouse?

-- Per state law whoever brings the child in and signed the financial agreement is who is financially responsible for your Childs balance. The statement will be sent to the person who we have a financial agreement with. If there is a divorce decree that says otherwise, it will be up to you to forward that bill to your ex-spouse. We do not have the authority to enforce your divorce decree, so can not bill them directly. Ultimately, regardless of what the divorce decree may state, you are who we have an agreement with and you will be held responsible for the balance.

 

How do I know when my claim has been processed by my insurance?

-- After your insurance processes your claim, they will send you out an eob (explanation of benefits) that will have the details of your claim. The eob will show what was or was not paid. If any services were denied, the reason why and the amount that will be due from you will be stated on that explanation of benefits. You may receive your eob up to 2 weeks before it gets posted to your account. If the insurance has your claims on hold, you may receive a letter requesting information. It is important that you respond to your insurance promptly to those requests for your claims to process in a timely manner.

 

What if my insurance denies my claims for pre-existing condition?

-- A lot of insurances will put a ‘pre-existing condition’ status on new members for a certain time period. Any claims submitted during that time period will most likely be reviewed. Meaning, that the insurance company will request any previous medical records for review. If it is determined that the concern and/or treatment is ongoing your claim may deny for a pre-existing condition. If that is decided and you disagree, it is advised that you contact your insurance and discuss the situation with them.

 

What if my insurance denies a service as non-covered?

-- If your insurance denies a service as non-covered it is your responsibility. It is a good idea to contact your insurance prior to seeing the doctor to verify which services are covered under your plan. The insurance companies will not guarantee payment until after the claim is processed, but they can give you an idea of what may or may not be covered under your plan.

 

How do I know which of my insurance policies is primary and which is secondary?

-- If you have more than one insurance policy, the insurances will have to determine which of them is primary and which is secondary. You will need to contact all your insurances to give them each others information (insurance carrier name, policy holder, other insurances effective dates and phone number). Once they have the information they need, they will then determine which is primary and which is secondary. In most situations the cob (coordination of benefits) is determined by the policy holders’ birthday. Whichever policy holders’ birthday is first in calendar year will be primary. If the policy holders were never married or are divorced the cob may be determined by what the divorce decree states (who is to hold the insurance) or by who has custody. Both or all insurances will have to come to an agreement.

 

What if my insurance policies are both paying the claims as primary or denying claims?

-- If your insurance companies are both paying as primary or denying your claims, you will need to contact both policies to make sure they have the information they need. The insurance companies will not take any other policy or policy holder information from us. In order for them to update their system correctly the information will have to come from you. Until your insurances have the information they need, your claims will not be processed and the balance will be your responsibility.

 

How do I add my newborn to my policy?

-- Most insurance companies only allow 30 days from the date of birth for the baby to be added. You will need to contact your HR department to fill out the forms needed so that your baby can be added to your policy. It is very important that you make sure all the information on the forms is correct (i.e.: date of birth, spelling of the Childs’ name and gender). If any of the information does not match when the claim is submitted, your claim may deny.

 

What can I do if I don’t agree with the way my insurance processed my claim?

-- The insurance will process your claims according to your plan benefits. You will first want to make sure that you understand your plan benefits. If you find that the insurance processed your claim incorrectly, you will want to call them to go over the claim in detail. Most of the time your insurance company will update and reprocess the claim over the phone. If your claim was indeed processed incorrectly, your insurance will send us an updated explanation of benefits. Until that is received, you will still be responsible for the balance. You can also do a member appeal in writing to your insurance company. You can either call your insurance for the address information and what is needed to do an appeal, or you can refer to your insurance benefit manual.

 

What is timely filing? How do I know if my insurance has timely filing?

-- All insurance companies have a time limit for submitting medical claims. Most insurances allow a year from the date of service to submit a claim. There are some insurances that only allow 90-120 days to submit a claim from the date of service. It is important that when you come in to see the doctor that you supply us with the most current and correct insurance information so your claims can be filed within the allotted time period. If we do not have your insurance information and do not receive it until after the allotted time limit for your insurance, we can not submit the claim. In the instance that it is past the timely filing limit and your card was not presented at the time of service the balance will be your responsibility. To find out what the time limit for submitting claims to your insurance is, it is best to contact your insurance.